Treatment for epiphora generally does not engender the roiling discussions that some ophthalmologic procedures do. Nonetheless, for many ophthalmologists who treat tearing patients, the source of the problem, and the optimal surgical solution, are not clear cut. Some ophthalmologists favor performing the more definitive dacryocystorhinostomy (DCR), whereas others prefer to offer the patient a less invasive lid-tightening procedure.

Room for Debate

Robert G. Fante, MD, clinical associate professor of ophthalmology at the University of Colorado in Denver, moderated a point-counterpoint session addressing the two approaches at the Academy’s Subspecialty Day in Chicago. The question posed to the panelists was: How do you treat tearing patients who do not have obvious dry eye, outflow blockage or lax eyelids? Dr. Fante noted that a survey of attendees conducted at the beginning of the session revealed that the majority of the audience trended toward performing DCR in these situations.

Noted experts in treating epiphora—John B. Holds, MD, clinical professor of ophthalmology and otolaryngology–head and neck surgery at Saint Louis University, and Geoffrey E. Rose, DSc, MBBS, a consultant ophthalmic surgeon at Moorfields Eye Hospital in London, congenially debated the merits of the two approaches in the point-counterpoint session.

Just pull it together. Dr. Holds—who has published widely on the subject—argued in favor of lower lid tightening with a lateral, tarsal-strip procedure. He noted the extensive documentation in the literature supporting the effectiveness of the lid-tightening approach. He also pointed to the procedure’s simplicity, the easily understood anatomy involved, the familiarity that any board-certified ophthalmologist has with the technique and the fact that lid tightening does not require expensive instrumentation.

Nope—poke a hole. Dr. Rose made the case for DCR, noting that the procedure reduces resistance to lacrimal outflow even among people who have no obvious obstruction in their lacrimal drainage system. These individuals may have a mild amount of outflow resistance that is difficult to document clinically, as well as some stasis of the tears as they drain into the nose. As a result, he said, many patients who do not appear to be candidates for a DCR will actually benefit from the procedure.

Four Nuanced Observations

Drs. Fante and Rose were joined in an EyeNet discussion of this topic by Tamara R. Fountain, MD, and Eric M. Hink, MD, and all four elaborated on their reasons for preferring one procedure over the other in specific clinical situations.

DCR can be right, or it can be overkill. “It’s unequivocal that if a patient has a nasolacrimal duct obstruction, they need a DCR,” said Dr. Fountain, professor of ophthalmology at Rush University in Chicago. “This is not an area of controversy because DCR is a very defined procedure with a very high success rate for a very specific problem. Lid tightening becomes an option for people who have a normal lacrimal drainage system—with no anatomic reason why fluid can’t get through—but have trouble getting their tears to where they can flow outward,” Dr. Fountain continued. “Tightening their lid makes the lacrimal pump mechanism more efficient.”

First, ensure orbicularis tension. Dr. Fante said that he leans toward performing DCR in his practice. But he agrees that even a slight loosening of the lower eyelid interferes with the efficiency of the lacrimal pump, and this can be corrected with a lid-tightening procedure. “If the eyelid gets even a little loose, the four Torricelli [torr] of pressure being generated can drop to three, two, one or even zero, and pumping will stop,” he said. “The lateral tarsal strip procedure reestablishes tension in the orbicularis muscle, making the blinking more efficient and enabling the tears to be delivered to the medial canthus more effectively.” Dr. Fante added that an ophthalmologist who regularly performs lateral tarsal strips can complete one in about 15 minutes, whereas it may take 30 minutes for someone who does them less often. For many patients, lid tightening can be a long-term solution to the problem, without the need for general anesthesia.

No lid laxity? Pump works? Do a DCR. Dr. Hink, who is in private practice at Allure Cosmetic Surgery, in Kirkland, Wash., said that for a patient who is tearing but has a patent lacrimal system, he typically goes to a lid-tightening procedure first if there is any evidence of lid laxity. “In a patient who doesn’t have true lid laxity and has good apposition of the eyelid and in whom you are not worried about the function of the lacrimal pump, I’d be more inclined to do a DCR,” Dr. Hink said.

DCR is the more definitive solution. Dr. Rose noted that lid tightening only increases tear delivery to the puncta whereas, in most cases, DCR increases flow throughout the system. He added that easing the outflow of tears with a DCR may also prevent future nasolacrimal duct obstruction by allowing inflammatory cells and inflammatory mediators, as well as allergens, bacteria and viruses, to drain more freely from the eye.

Some Restrictions

The potential downsides to DCR include its greater complexity and more challenging anatomy, which make the procedure less accessible to some comprehensive ophthalmologists. “Most have done some DCRs during their residency,” Dr. Fante said, “but may not feel comfortable performing the procedure five or 10 years after their training.”

As always, experience counts. Dr. Rose contended that “both procedures are relatively straightforward if they are taught well and you have performed your first 300. Clearly, however, an ophthalmologist who does relatively little lid and lacrimal surgery will feel less comfortable with areas of greater anatomical variation.”

Don’t rely on an endoscope. Asked to comment about endoscopically performed DCR, Dr. Rose expressed his belief that “endonasal surgery can never achieve as much as properly performed external surgery.”

And don’t leave stents in forever. What about the role of silicone stents in treating excessive tearing? “Stents are an epithelial policeman and can be removed when the fibrinous phase of healing is complete, about two weeks after surgery,” Dr. Rose said. “They have absolutely no role in keeping a properly performed rhinostomy open and should not be left in for more than six weeks or so.” As with the other topics related to treating epiphora, these remain areas of debate.

No Cut-and-Dried Protocol

Dr. Fountain framed the two approaches to the tearing patient who does not have a blockage this way: “Some ophthalmologists say, ‘Why put someone through an operation, remove their bone and give them a facial scar in order to correct their tearing when they don’t really have a blockage—and we never know for sure whether the person will benefit from the operation.’ But with lid tightening, only about half of patients will notice an improvement.”

Every patient is different, so just be honest. “I am very candid going into lid-tightening procedures,” Dr. Fountain continued. “I lower patients’ expectations, telling them that they might benefit or they might not, but that it’s a fairly minor procedure to go through. So they accept their odds, and afterward if it didn’t help, at least it wasn’t too much of a hassle to go through. The choice of procedures is not cut and dried because if it were, one of the two would be standard of care. Usually, if there is a controversy over two procedures, it just means that both are accepted—and sometimes that we just don’t have an ideal treatment for the problem.”
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Dr. Fountain is a consultant for the Ophthalmic Mutual Insurance Company. Drs. Fante, Hink and Rose report no financial interests.

Catch What You Missed

A DVD-ROM from the Subspecialty Day “Oculofacial Plastic Surgery 2010: Decades of Progress: What’s Next?” is available for purchase.

To order, please visit www.aao.org/meetings/annual_meeting, then click on “Meeting Archives.” Scroll down to DVD-ROMs and click “2010.” This will take you to the Learner’s Digest website where you can place your order.